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. 2022 Sep 30;75(7):1187-1193.
doi: 10.1093/cid/ciac074.

Clinical Decision Support Systems to Reduce Unnecessary Clostridioides difficile Testing Across Multiple Hospitals

Clare Rock  1 , Oluchi Abosi  2 , Susan Bleasdale  3 , Erin Colligan  4 , Daniel J Diekema  5 , Prashila Dullabh  4 , Ayse P Gurses  1 , Krysta Heaney-Huls  4 , Jesse T Jacob  6 , Sheetal Kandiah  6 , Sonam Lama  4 , Surbhi Leekha  7 , Jeanmarie Mayer  8 , Alfredo J Mena Lora  3 , Daniel J Morgan  7 , Patience Osei  1 , Sara Pau  1 , Jorge L Salinas  5 , Emily Spivak  8 , Eric Wenzler  9 , Sara E Cosgrove  1
Affiliations

Clinical Decision Support Systems to Reduce Unnecessary Clostridioides difficile Testing Across Multiple Hospitals

Clare Rock et al. Clin Infect Dis. .

Abstract

Background: Inappropriate Clostridioides difficile testing has adverse consequences for patients, hospitals, and public health. Computerized clinical decision support (CCDS) systems in the electronic health record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into healthcare providers' (HCP) workflow are not well understood.

Methods: Nine academic and 6 community hospitals in the United States participated in this 2-year cohort study. CCDS (hard stop or soft stop) triggered when a duplicate C. difficile test order was attempted or if laxatives were recently received. The primary outcome was the difference in testing rates pre- and post-CCDS interventions, using incidence rate ratios (IRRs) and mixed-effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary nodes and subnodes.

Results: In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing incidence rate (IR) reduction was 33% (95% confidence interval [CI]: 30%-36%) and 23% (95% CI: 21%-25%), respectively. Two hospitals implemented a non-EHR-based human intervention with IR reduction of 21% (95% CI: 15%-28%). HCPs reported generally favorable experiences and highlighted time efficiencies such as inclusion of the patient's most recent laxative administration on the CCDS. Organizational factors, including hierarchical cultures and communication between HCPs caring for the same patient, impact CCDS acceptance and integration.

Conclusions: CCDS systems reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow and when displaying relevant patient-specific information needed for decision making.

Keywords: C. difficile testing; Clostridiodes difficile; clinical decision support; diagnostic stewardship.

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Conflict of interest statement

Potential conflicts of interest. D. J. D. reports a grant to his institution for a clinical trial of new susceptibility test systems from bioMérieux, outside of the conduct of the study; payment for consulting on novel diagnostics from OpGen; and payment for consulting on antimicrobial resistance surveillance studies from JMI Laboratories. A. P. G. reports grants or contracts from the Agency for Healthcare Research and Quality (AHRQ), the CDC, and the National Institutes of Health (NIH), outside of the conduct of the study; payment for lecture from the North Carolina Health Association; and Human Factors and Ergonomics Society Executive Council. J. J. reports royalties from UpToDate. D. J. M. reports grant funding to support infection prevention and medical decision making research from the CDC, NIH, AHRQ, and the Veterans Affairs Health Services Research and Development Service, and reimbursement for travel related to meeting planning on speaking at meetings from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. All other authors report no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

References

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